Questions regarding ordering diagnostic tests, and referrals for other treatment
1) Ordering diagnostics and referral for other treatment
If you are having trouble getting the insurer to authorize a diagnostic imaging study, WCD has a rule that can force the insurer to act: OAR 436-010-0230 (12) (Effective Oct. 1, 2015) indicates that a medical provider may contact an insurer in writing for pre-authorization of diagnostic imaging studies other than plain film X-rays. The insurer is required to respond to the provider's request in writing whether the service is pre-authorized or not pre-authorized within 14 days of receipt of the request.
For other services, such as physical therapy or EMG studies, the WCD has indicated that the insurer cannot ignore requests for preauthorization as it can stall the worker’s ability to access the care needed to get better. If providers want preauthorization for services, we recommend requesting that in writing so a record can be tracked if a medical dispute must be made to force the insurer to make a decision.
A Requests for Surgery must be in writing, and the WCD mandates that the insurer has 7 days to respond.
2) Treatments that can be provided under a closed claim
While curative medical care is only available under an open claim, you can provide a certain kind of medical treatment to injured workers with a closed claim. The following are some examples of medical treatment available to an injured worker with a closed claim:
- You may prescribe ongoing prescription medication for a patient with a closed claim.
- Order diagnostic services. Diagnostic treatment can be especially helpful under a closed claim if your patient has ongoing complaints and you suspect they may be suffering from a newly developed condition, a condition that has not yet been identified, or when there has been a worsening of an existing condition (for more information, see the section on aggravation and new/omitted condition claims below).
- Palliative care to temporarily restrict or reduce the intensity of an otherwise stable condition. Palliative care is available to injured workers who are working or engaged in vocational retraining where treatment is necessary to enable the worker to continue in current employment or vocational retraining. You must submit a written request for palliative care to the insurer. In it, you must identify the condition for which palliative care is being requested, as well as objective findings. In the written request you must also include a treatment plan with the names of the provider who will provide the care, and specify the treatment modalities and the frequency and duration, not to exceed 180 days, and explain how the services will help your patient to continue employment or vocational retraining. The insurer has 30 days to approve a palliative care plan.
- Curative care that is generally only available for open claims is available under a closed claim in order to stabilize a temporary and acute waxing and waning of symptoms.
- Curative care for an aggravation of an injury where the compensable work injury has worsened and may require comprehensive medical treatment or even surgery for your patient to get back to medically stationary status (see section below on aggravation claims).
Importance Of Providing Work Restrictions
Injured workers may be entitled to time loss (wage replacement) benefits if they are completely unable to work. They may also be entitled to time loss benefits if they are capable of modified work but their employer does not have modified work available. However, an injured worker is only entitled to time loss benefits if a doctor takes him or her off work or provides work restrictions in writing. You must specify if the injured worker is to remain off work or has with work restrictions after every visit. You may also specify an open ended work restrictions by indicating in writing that your patient is off of work until further notice. Additionally, retroactive work restrictions can be authorized for up to 14 days.
If an injured worker's claim has been denied, it is important to continue to provide work restrictions or provide an open ended work restriction if applicable. That way, if the injured worker prevails over the denial, they will be able to recoup time loss benefits owed while their claim was in denied status. It is also important to continue to provide work restrictions when applicable even if the injured worker has been terminated from employment and is not working.
Getting Paid For Medical Services
If you are not paid for medical services provided to an injured worker because the claim is denied, the insurer is required to pay your bills if the denial is overturned or if the injured worker enters into a Disputed Claim Settlement (DCS) with the insurer. It is important that you continue to bill the insurer even where a claim has been denied because if an injured worker wins at a hearing, the insurer must pay all of the medical bills in its possession after a judge’s order is final. If an injured worker enters into a Disputed Claim Settlement (DCS), any medical bills in the insurer’s possession must be paid out of that settlement.
If you are treating an injured worker with an accepted claim but your medical bills are not getting paid, you may need to initiate a medical services dispute with the Workers’ Compensation Division. You can initiate a dispute with Form 2842 available on the Oregon Workers’ Compensation Division website.
If you are aware that your patient has an attorney, you should reach out to the attorney directly for assistance with any unpaid or denied medical bills. For attorneys that represent injured workers it is a priority that our clients get the treatment they are entitled to and that their medical providers get paid for services.
Q: When should the provider make an aggravation claim?
A: Providers generally make aggravation claims before getting the diagnostic services they need to substantiate whether a pathological worsening has occurred. You can order these diagnostic services under a closed claim without first filing an aggravation claim. Doing so prevents unnecessary litigation and excess claims processing for claims that were made prematurely.
Q: When should the provider tell the worker to ask for a new condition to be accepted?
A: If you suspect that the worker suffered more than the simple strain or contusion condition accepted, you should order the diagnostic tests you need to confirm your diagnosis before suggesting that the worker add this condition to the claim.
The best way to frame your request for diagnostics for a condition that is not accepted under the claim is to just say you "need these diagnostic services to determine the nature and extent of the work injury."